=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306854203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHALEELUR R ZACKARIYA SR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5215 HOLYCROSS PARKWAY
-----------------------------------------------------
City | MISHIWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-237-7168
-----------------------------------------------------
Fax | 574-472-6262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 PARK PL
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-472-6901
-----------------------------------------------------
Fax | 574-472-6262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 01066056A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 01066056A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036098582
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------